Facilities Request Form

This application must be completed and submitted no later than one week prior to use.

*Person in Charge of Activity:

*Sponsoring Organization:

*Address:

*City:

*Phone:

Email:

*Purpose or Type of Activity:

*Approx. # who will use the space:

Building(s) Requested:

High School

Hilltop

Park Elementary

Ziebarth Family Learning Center

*Area or Room(s) fRequested:

*Dates and Times Requested:

Time Doors are to be opened

(indicate AM/PM):

Time of departure

(indicate AM/PM)

Special equipment or room arrangements:

Check if you need any of the following:

Custodian

Cook

Do you have a certificate of insurance on file at the school?

Name of Insurance Agency:

Insurance Agent:

The Board strongly recommends that groups using a school facility secure the proper insurance.LIABILITY STATEMENT
The purpose of this statement is to determine liability in the event of damage to buildings and/or bodily injury that occurs as a result of the applicant or applicant’s organization using the facility. Any individual or group who is authorized to use the school facilities may be judged responsible for liabilities resulting from bodily injuries or building damages that occur during the time that the facility is authorized for use by the applicant. By submitting this form, you indicate that you have read and understand this liability and that you agree to pay rental fees and custodial or cook’s salaries, if any, as outlined in the fee schedule.

SUPERVISION and CLEANING
I also take responsibility for supervising the actions of my group while they occupy the building. I understand that the school buildings are tobacco-free, and alcohol is not allowed on the premises. Furthermore, I understand that I must restore the room to its original condition and order. If additional custodial time is required, I understand that I will be charged for these services.

* Indicates Required fields.

Security Measure

ISD 2397Le Sueur-HendersonPublic Schools

115 1/2 North 5th Street, Le Sueur, MN 56058

Phone 507-665-4600 | Fax 507-665-6858

Le Sueur-Henderson Schools does not discriminate on the basis of race, color, national origin, sex, age, or disability in admission to its programs, services, or activities, in access to them, in treatment of individuals, or in any aspect of their operations. The lack of English language skills shall not be a barrier to admission or participation in the district's activities and programs. Le Sueur-Henderson Schools also does not discriminate in its hiring or employment practices.